Practice Patterns and Ethical Considerations in the Management of Venovenous Extracorporeal Membrane Oxygenation Patients: An International Survey*
Practice Patterns and Ethical Considerations in the Management of Venovenous Extracorporeal Membrane Oxygenation Patients: An International Survey*
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DOI：
10.1097/ccm.0000000000003910
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发表时间：
2019-10-01
影响因子：
8.8
通讯作者：
Ranieri, V. Marco
中科院分区：
文献类型：
--
作者：
Abrams, Darryl;Pham, Tai;Ranieri, V. Marco
目的：描述医生对严重呼吸衰竭开始、限制和退出静脉-静脉体外膜氧合的做法和态度，并评估与这些态度相关的因素。设计：电子，横断面，基于场景的调查。环境：隶属于体外生命支持组织和国际体外膜氧合网络的体外膜氧合中心。对象：具有管理接受静脉-静脉体外膜氧合的成年患者经验的主治医师。干预措施:没有。测量和主要结果：来自六大洲39个国家的539名医生完成了调查。影响决定限制体外膜氧合启动的因素包括患者年龄较大（46.9%），额外的器官衰竭（37.7%）和延长机械通气（35.1%）。患者合并症（70.5%）、患者意愿（56.0%）和呼吸衰竭病因（37.7%）是影响决定退出体外膜氧合的因素。在多变量分析中，与退出维持生命治疗的几率增加相关的因素包括肺纤维化、中风、代理人的退出意愿、对纤维化情况下患者或代理人的意愿缺乏了解、基线情况下未启动体外膜氧合以及受访者的宗教信仰。与戒断几率降低相关的因素包括在一个法律上不可能违背患者或代理人意愿的环境中执业。大多数受访者（90.5%）在体外膜氧合患者的治疗决策中涉及其他医生，而分别只有53.2%、45.3%和29.5%的受访者涉及代理人、清醒患者或床边护士。结论：患者和医生层面的因素与体外膜氧合启动和退出的决策相关，包括患者预后和对患者或代理意愿的了解。受访者报告说，在管理接受体外膜氧合的患者时，参与共同决策的比例很低。
Objectives: To characterize physicians' practices and attitudes toward the initiation, limitation, and withdrawal of venovenous extracorporeal membrane oxygenation for severe respiratory failure and evaluate factors associated with these attitudes. Design: Electronic, cross-sectional, scenario-based survey. Setting: Extracorporeal membrane oxygenation centers affiliated with the Extracorporeal Life Support Organization and the International Extracorporeal Membrane Oxygenation Network. Subjects: Attending-level physicians with experience managing adult patients receiving venovenous extracorporeal membrane oxygenation. Interventions: None. Measurements and Main Results: Five-hundred thirty-nine physicians in 39 countries across six continents completed the survey. Factors that influenced the decision to limit extracorporeal membrane oxygenation initiation included older patient age (46.9%), additional organ failures (37.7%), and prolonged mechanical ventilation (35.1%). Patient comorbidities (70.5%), patient's wishes (56.0%), and etiology of respiratory failure (37.7%) were factors that influenced the decision to withdraw extracorporeal membrane oxygenation. In multivariable analysis, factors associated with increased odds of withdrawing life-sustaining therapies included pulmonary fibrosis, stroke, surrogate's desire to withdraw, lack of knowledge regarding patient's or surrogate's wishes in the setting of fibrosis, not initiating extracorporeal membrane oxygenation in the baseline scenario, and respondent religiosity. Factors associated with decreased odds of withdrawal included practicing in an environment where it is not legally possible to make decisions against patient or surrogate wishes. Most respondents (90.5%) involved other physicians in treatment decisions for extracorporeal membrane oxygenation patients, whereas only 53.2%, 45.3%, and 29.5% of respondents involved surrogates, awake patients, or bedside nurses, respectively. Conclusions: Patient and physician-level factors were associated with decision-making regarding extracorporeal membrane oxygenation initiation and withdrawal, including patient prognosis and knowledge of patient or surrogate wishes. Respondents reported low rates of engaging in shared decision-making when managing patients receiving extracorporeal membrane oxygenation.